Journal of Applied Dental and Medical Sciences

NLM ID: 101671413 ISSN:2454-2288

Volume 2 Issue 1 January - March 2016
Review Article

Molar Distalization By Miniplates- A Review

Neeraj Patil 1, Veerendra Kerudi 2, Harshal A Patil 3, Pawankumar D. Tekale 4, Prasad Bonde5, Siddhesh Dolas 6
1,2
Professor, Department of Orthodontics, ACPM Dental College and Hospital, Dhule, India.
3,5,6
Senior Resident, Department of Orthodontics, ACPM Dental College and Hospital, Dhule, India..
4
Senior Lecturer, Department of Orthodontics, Dr Rajesh Ramdasji Kambe Dental College and Hospital, Akola, Maharashtra. India.

ARTICLE INFO ABSTRACT

Treatment of Class II malocclusions, without extractions, frequently requires distalization of maxillary

molars into a Class I relationship by means of extra-oral or intraoral forces. Several methods and devices
can be used to distalize maxillary molars and to correct Class II malocclusions. The most conventional
method for distalizing the maxillary molars involves use of cervical headgear but the success of the
treatment depends heavily on patient cooperation. Several intraoral appliances have been used to distalize
the maxillary molars in Class II patients without the patients cooperation; these include nickel-titanium
spring, magnet distal jet, first class, Jones jig, pendulum, and Keles slider appliances.

Keywords:
Molar Distalisation, Orthodontic
movement, mini plates

Introduction protrusion of maxillary incisors, an increase in overjet,

Treatment of Class II malocclusions, without and decrease in overbite. Anchorage, defined as a
extractions, frequently requires distalization of resistance to unwanted tooth movement1, is a
maxillary molars into a Class I relationship by means prerequisite for the orthodontic treatment of dental and
of extra-oral or intraoral forces. Several methods and skeletal malocclusions.2,3
devices can be used to distalize maxillary molars and In1983, the first clinical use of a screw for orthodontic
to correct Class II malocclusions. The most anchorage was reported.4After that, temporary skeletal
conventional method for distalizing the maxillary anchorage devices were rapidly developed. There have
molars involves use of cervical headgear but the been 3 major trends in the field of temporary skeletal
success of the treatment depends heavily on patient anchorage devices: palatal implants, miniscrews, and
cooperation. Several intraoral appliances have been miniplates. When compared with the other temporary
used to distalize the maxillary molars in Class II skeletal anchorage systems, miniplates offer better
patients without the patients cooperation; these stability. The average failure rates are 7.3% for
include nickel-titanium spring, magnet distal jet, first miniplates, 10.5% for palatal implants, and 16.4% for
class, Jones jig, pendulum, and Keles slider miniscrews.5
appliances. All of these intraoral distalization In the history of miniplate anchorage in orthodontics,
appliances distalize the maxillary molars; however the first use of a surgical bone plate for orthodontic
anchorage loss was unavoidable, characterized by the anchorage was reported in 1985.6Since that time, a

* Corresponding author: Dr. Harshal Ashok Patil,Affiliation: Senior Resident, Department of Orthodontics, ACPM Dental College and Hospital, Dhule, India.
Contact No- 9890202048 Mail id: drharshalortho@gmail.com

number of miniplate systems have been specially
designed as orthodontic anchors. A skeletal anchorage
system, with its anchor plates and screws made of pure
titanium, was developed in 1999 for use as absolute
orthodontic anchorage units.7,8The skeletal anchorage
system was monocortically placed, and this allowed
rigid anchorage because of the osseointegration effects
on both the anchor plates and the screws.9 The failure
rate of the skeletal anchorage system is 6%, and it
10
shows excellent clinical performance. A zygomatic
anchorage system, consisting of plates and screws,
also a rigid anchorage system, was introduced in
11
2002. The success rate of the zygomatic anchorage
12
system was 98.6%. In another example, a locking
plate (Compact lock 2.0)has been used as posterior
maxilla anchorage,13 and its success rate is 93.4%.14
Miniplates are widely used in maxillofacial surgery as
osteosynthesis devices for facial fracture repair and for
fixation osteotomies. Miniplates used
orthodontic practice are modified devices with a
connection bar passing through the attached gingival.
They overcome the disadvantages of miniscrew
implants, such as difficulty in finding a suitable site,
and can serve as more reliable and long standing
skeletal anchorage units that provide excellent
stability. The fixation screws of miniplates can be
placed at various regions of the maxilla and mandible (
zygomatic buttress or aperture piriformis of the
maxilla, posterior cortical bone and symphyseal
regions of the mandible) . Miniplates present however
some disadvantages; they are more expensive than
miniscrews, they must be placed by a maxillofacial
surgeon in an operating room and both placement and
removal may cause swelling and discomfort for the
patient.
Journal Of Applied Dental and Medical Sciences 2(1);2016
MOLAR DISTALIZATION 2(1);2016 124
Miniplates have been used for skeletal anchorage for
intrusion or distalization of molars, in en masse
distalization of the entire dental arch, for buccal
segment distalization, for severe skeletal class 3 as an
alternative to orthognathic surgery or where anchorage
teeth are lacking, and to apply orthopedic forces for
treatment in both class 2 and class 3 cases.
Structure and composition of miniplates
Miniplates are made of titanium or titanium alloys and
come in various shapes and sizes. All miniplates have
3 parts: head, arm, and body. The head portion is intra-
orally exposed and positioned outside the dental
arches. The head comes in a variety of shapes:
circular,15 hooked,16,17 and tubular.18Some are like
bendable sticks that can be manipulated into the
desired shape.19The arm portion is transgingival or
transmucosal and tends to be rectangular or round. The
in the body portion is positioned subperiosteally, and its
surface is attached to the bone. The body portions are
classified into 4 basic shapes: T, L, Y, and I (straight).
The body portion is fixed on the bone surface of the
zygomatic buttress or the mandibular body with 2 or 3
miniscrews. Although there are many variations in
miniplate heads, there are fewer variations in the body
portions. Standard miniplates, used in maxillofacial
surgery, are also used for orthodontic anchorage but
the emergence area is not rounded and they have sharp
corners, which can cause delayed wound healing and
more soft tissue irritation.
Yen-Wen Huang et al20. concluded that The peak von
Mises cortex stress values were highest with the I-type
plates followed by the L-type, Y-type, and T-type
plates. Bone stress decreased as the screw numbers
increased but was not related to screw length. Bone
stress increased as the cortex thickness decreased.

Bone stress was linearly proportional to the force
magnitude, and the highest values were produced
when the force was in the forward direction.
Various system of miniplate for Distalization
1. The Zygoma Anchorage System
21
In 2002 Hugo De Clerck etal developed a new
anchorage system (ZAS)in which the miniscrews are
placed at a stage distance from the roots of the upper
molars. Because of its location and its solid bone
structure, the inferior border of the zygomatico
maxillary buttress, between the first and second
molars, was chosen as the implant site. Combining
three miniscrews with a titanium miniplates can bring
the point of the force application near the center of
resistance of the first permanent molar.
Appliance Design and Placement
The upper part of the Zygoma Anchor is a
titanium miniplate with three holes, slightly curved to
fit against the inferior edge
zygomaticomaxillary buttress, A round bar, 1.5 mm in
diameter, connects the miniplates and the fixation unit.
A cylinder at the end of the bar has a vertical slot,
where an auxiliary wire with a maximum size of
0.032 x 0.032 can be fixed with a locking screw.
The plate is attached above the molar roots by three
self tapping titanium miniscrews, each with a diameter
of 2.3 mm and a length of 5mm or 7mm. the
miniscrews do not need to be sandblasted, etched, or
coated. Square holes in the center of the screw heads
accommodate a screw driver for initial placement,
while pentagonal outer holes are used to remove the
screws at the end of treatment. To place the anchor, an
L-Shaped incision, consisting of a vertical incision
mesial to the tress and a small horizontal incision at
the border between the mobile and attached gingival,
Journal Of Applied Dental and Medical Sciences 2(1);2016
MOLAR DISTALIZATION 2(1);2016 125
is made under local anesthesia. The mucoperiosteum is
elevated, and the upper part of the anchor is adapted to
the curvature of the bone crest. Three holes with a
diameter of 1.6mm each are drilled, and the Zygoma
Anchor is affixed with the three miniscrews. The
Cylinder should penetrate the attached gingiva in front
of the furcation of the first molar roots at a 90 angle to
the alveolar bone surface. The miniplate is covered by
the mucoperiosteum and sutured with resorbable
stitches. When indicated, premolars are extracted at
the same appointment.
Clinical Application
To connect the Zygoma Anchor with the anterior teeth
a rigid power arm was designed to fit in the large
vertical slot of a canine bracket.The hook at the end of
the power arm is situated at the level of the canines
center of resistance. A nickel titanium closed coil
spring with a force of 50-100gm is attached between
the power arm on the canine and the Zygoma Anchor,
of the so that. The direction of force is parallel to the main
archwire.
The first molar can be distalized with a sliding
jig before force is applied to the upper canines. The
ZAS can also be used with open coil springs to
neutralize the reaction forces generated by distal
movement of the upper molars. During retraction and
intrusion of the anterior segment with T-loop arches,
the ZAS is used as an indirect anchorage unit.
After orthodontic treatment the mini screw are
removed under local anesthesia through a small
vertical incision in the gingival convering the
miniplate. A special screwdriver that fits into the
pentagonal outer holes of the screw heads is used.
After the screws are removed, only three 1.6mm
diameter holes remain, minimizing bone loss.
 MOLAR DISTALIZATION 2(1);2016
The ZAS uses three miniscrews, increasing total
anchorage over other types of implants. Because the
miniscrews and miniplate have excellent mechanical
retention, immediate loading is possible. The point of
application of the orthodontic forces is brought down
to the level of the furcation of the upper first molar
roots. The vertical slot with the locking screw makes it
possible to attach an Auxiliary wire, which can move
the point of force application some distance from the
anchor. The connection between the anchor and the
conventional fixed appliance can easily be adapted to
changing anchorage needs throughout treatment. So,
ZAS seems to be an effective alternative to
conventional extraoral anchorage.
2. Skeletal Anchorage System for Distalization
22
Sugawara et al. in 2006 developed the
Skeletal Anchorage System (SAS), which is a
noncompliance appliance that uses a similar concept as
the palatal implant system, but mechanically differ
from it. The SAS consists of titanium anchor plates
and monocortical screws that are temporarily placed in
either the maxilla or the mandible or in both, as
absolute anchorage units for adult orthodontics. And it
is possible to move maxillary molars distally with
ease.
Anchor plates were made up of pure titanium
and therefore were suitable for osseo-integration and
tissue integration. Also, they were sufficiently strong
to resist the usual orthodontic forces even at the
headgear force level, and could be bent with ease for
fitting into the bone contour of the implantation site.
The head position was intra-orally exposed and
positioned outside the dentition so that it never
disturbed the distalization of the maxillary molars.
Each head portion has 3 continuous hooks for easier
application of the orthodontic force vactors. The arm
Journal Of Applied Dental and Medical Sciences 2(1);2016
126
portion was transmucosal and had 3 graduated lengths,
short (6.5mm), medium (9.5mm) and long (12.5mm)
to compensate for individual morphological
differences. The body portion was positioned
subperiosteally.
The implantation sites of the anchor plates
required sufficiently thick cortical bone, at least 2 to 3
mm, to enable fixation of the anchor plates with
monocortical miniscrews. The screws were also made
of pure titanium. Each screw had a head with a tapered
inside square an self tapping thread. The diameter of
the screw was 2mm and the available length was 5mm.
The anchor plates were placed at the zygomatic
buttress to distalize the maxillary molars.
For placement of anchor plates, the operation
was carried out under local anesthesia administered
with intravenous sedation. First, a mucoperiosteal
incision was made at the buccal vestibule of the
implantation site. A mucoperiosteal flap was elevated
after subperiosteal ablation and the surface of the
cortical bone at the implantation site was exposed. The
anchor plate was selected according to the distance
between the implantation site and the dentition. The
selected plate was contoured to fit the bone surface.
Then a pilot hole was drilled, and a self tapping and
monocortical screw was inserted. After the placement
of the remaining screws, the anchor plate was then
firmly attached to the bone surface. The wound was
closed and sutured with absorbable thread. The surgery
took 10 to 15 minutes for each anchor plate.
Orthodontic force was usually applied about 3
weeks after the implantation surgery. After post-
surgical management, but it was not necessary to wait
for the osseointegration of the titanium screws and
plates. All anchor plates were removed immediately
after debonding.
 MOLAR DISTALIZATION 2(1);2016
For Distalization first 0.022 slot preadjusted multi
bracketed appliance placed. Heat treated 0.018 x
0.025 blue Elgiloy wires were used as the main
archwires for distalization of the maxillary molars. The
orthodontic forces were approximately 200gm for
single molar distalization and approximately 500gm
for enmass molar distalization. Orthodontic forces
were mostly provided by nickel titanium springs or
elastic chain modules.
It is important to address the amount of
distalization of the maxillary first molars and
anchorage loss at the first stage. But a more important
matter is the anchorage slip of the distalized molars at
the second stage. The progress of the maxillary molar
distalization with the SAS is completely different from
previous molar distalizing methods. The distalized
molars are never required as part of the anchorage
during retraction of the premolars and the anterior
teeth, because the orthodontic anchor plates placed at
the zygomatic buttresses. It is possible to perform en
masse movement of the molars, the premolars, and
anterior dentition in sequence without a separation into
2 stages. The sequential and efficient distalization is a
distinct advantage of SAS biomechanics as compared
with previous methods.
Maxillary first molar distalization by SAS was
around 3.78 mm at the crown level; therefore, the SAS
can be considered an effective modality
noncompliance molar distalization. Also, distalization
at root level was 3.20 mm on average, distalization
with the SAS can be considered as bodily translation.
3. Zygoma-Gear Appliance For Intraoral Upper
Molar Distalization
Nur et al in 201023 designed an intraoral upper molar
distalization system supported by the zygomatic region
named as the Zygoma-Gear Appliance (ZGA).
Journal Of Applied Dental and Medical Sciences 2(1);2016
127
The system consists of two zygomatic anchor plates,
an inner-bow, and heavy intraoral elastics. The
zygomatic anchor is a titanium miniplate with three
holes, which continues into a round bar. The anchor
plate is adjusted to fit the contour of the lower face of
each zygomatic process and fixed by three bone
screws (length, 7.0 mm). The inner-bow is made from
stainless steel wire, 1.1 mm in diameter and designed
like the inner part of a conventional facebow. Two
hooks are soldered onto the inner-bow at the lateral
teeth regions, and U bends are bent bilaterally in front
of the upper first molars. The inner-bow is adjusted to
the headgear tubes on the upper first molar bands. A
distally directed force is applied to the upper molar
teeth via the heavy intraoral elastics, which are placed
between the zygomatic plate and the inner-bow hooks.
Results showed the mean treatment period required to
achieve a Class I molar relationship was 5.21 months.
The distalization amount of the maxillary molars was
4.37mm and, thus, the rate for the distal movement of
the molars was 0.84 mm per month. Maxillary first
molars showed a slight intrusion (0.50 mm), while
distal tipping was only 3.30 degree. Furthermore, there
was a decrease in overjet, indicating that there was no
anchorage loss with use of the ZGA and thus they
concluded that maxillary molar distalization without
anchorage loss can be achieved in a short time.
for Kilkis et al in 201224conducted a study to present the
orthodontic treatment of a 15-year-old boy with a
unilateral maxillary molar distalization system, called
the zygoma-gear appliance It consisted of a zygomatic
anchorage miniplate, an inner bow, and a Sentalloy
closed coil spring. A distalizing force of 350 g was
used during the distalization period. The unilateral
Class II malocclusion was corrected in 5 months with
the zygoma-gear appliance. The maxillary left first
 MOLAR DISTALIZATION 2(1);2016
molar showed distalization of 4 mm with an
inclination of 3 degree. The maxillary premolars
moved distally with the help of the transseptal fibers.
In addition, there were slight decreases in overjet (0.5
mm) and maxillary incisor inclination, indicating no
anchorage loss from the zygoma-gear appliance. This
study showed that this new system, the zygoma-gear
appliance, can be used for unilateral maxillary molar
distalization without anchorage loss.
Discussion
25-28
Several reports have shown different
appliances for molar distalization in the treatment of
dental Class II malocclusions. However, anchorage
loss of the maxillary premolars and flaring of the
maxillary incisors as well as a considerable amount of
relapse during retraction of the premolar and the
anterior teeth were reported.29 Therefore, intraoral
distalizing mechanics combined with palatal implants
have recently been used for distalization of maxillary
molars.30,31 Although these methods can be used
effectively to achieve distalization of maxillary molars
without anchorage loss, the retraction of the anterior
teeth is limited as a result of the proximity of palatal
implant to the roots of anterior teeth or the presence of
a bulky acrylic Nance appliance behind the upper
incisors. In addition, Liou et al.32 and Kinzinger et
33
al. examined the anchorage quality of the miniscrews
and concluded that they did not fully maintain their
positions under continuous loading. To overcame this
the use of miniplates for direct anchorage can support
all treatment required for distalization of the complete
maxillary dental arch with little need for patient
compliance during treatment apart from maintenance
of oral hygiene.
Journal Of Applied Dental and Medical Sciences 2(1);2016
128
The surgical intervention required for the
placement of miniplates is more invasive than that for
miniscrews. The other problem has to do with exactly
who should put the miniplate into place. With regard
to the surgical intervention, miniplates for distalization
is implanted at the zygomatic buttress a
mucoperiosteal flap operation is inevitable. After
implantation surgery, patients have facial swelling for
about a week. These clear disadvantages come hand in
hand with the use of miniplates. Thus, a risk-benefit
analysis must be carefully carried out to clarify
whether the patient will benefit significantly by the use
of miniplates rather than miniscrews.
Conclusion
Newer appliances continue to evolve as trend changes
from headgear to intra-oral appliances that attempt to
favorably alter the posterior relationships of the jaws
and occlusion and that also require a minimum of
patient cooperation. The newer materials like mini-
implants are no doubt revolutionizing the procedure of
molar distalization and with the todays scenario as the
non- extraction therapies are fast catching up, who
knows what the so called next generation force
delivery system may have in hands for us.
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